Examination Under Anesthesia Research Articles

Anorectal Agenesis with Rectovaginal Fistula: A Rare/Regional Variant.

Aims and Objectives:The anatomical types of female anorectal malformation (ARM) are complex and include several rare and regional variants. The aim of this report is to highlight the diagnosis and management of cases of anorectal agenesis with rectovaginal fistula (RVF).Materials and Methods:This is a retrospective chart review of cases of RVF who underwent definitive surgery between November 2000 and September 2016 in a single institution.Results:Of the 244 female patients with anorectal anomalies treated in our institution over a 16-year period, there were 15 cases of RVF with anorectal agenesis giving it an incidence of 6%. All cases of RVF with anorectal agenesis presented with absence of anal opening, varying degree of abdominal distension, and history of passage of fecal matter per vaginum. The mean age of presentation was 3 months (newborn to 1 year). Sigmoid colostomy was done in 13 cases. Distal colostogram demonstrated high RVF which was further confirmed by examination under anesthesia (EUA) and endoscopy before definitive surgery. With the posterior sagittal approach, division of the RVF and anorectoplasty was possible in 14 cases; however, one patient required an abdominal mobilization of the colon for pull through due to a very short distal bowel segment. During a mean postoperative follow-up of 5 years, cosmetic and functional results were satisfactory.Conclusion:RVF with anorectal agenesis is a rare/regional variant of female ARMs. Clinical examination along with distal colostogram, EUA, and endoscopy clinches the diagnosis. Anorectal reconstruction by posterior sagittal anorectoplasty results in a satisfactory outcome.

Role of MRI Fistulography with Gadopentate Enhancement in Assessment of Complex Anal Fistulas and Improving Surgical Outcomes

Preoperative assessment of complex fistula-in-ano (FIA) is crucial for decision making. Magnetic resonance imaging (MRI) has been used for assessment of perianal sepsis with various protocols and methods. The aim of the present study was to assess the concordance between MRI fistulography with gadopentate enhancement and the intraoperative surgical findings, and to study the impact of preoperative assessment with MRI on surgical outcomes including fistula recurrence and fecal incontinence (FI). Patients with complex and high FIA who were investigated by MRI fistulography preoperatively were reviewed. The concordance between the findings of MRI and the intraoperative findings on examination under anesthesia (EUA) was made using Kappa coefficient test. The accuracy and sensitivity of MRI were calculated regrading detection of the internal opening, primary and secondary fistula tracts. 95 patients (82% males) were included in the study. MRI fistulography had an accuracy of 89.4%, 96.8%, 96.8%, 98%, and 98% in detection of the internal opening, number of tracts, position of primary tract, secondary extensions, and presence of abscess cavities, respectively. Overall, there was very good concordance between MRI and EUA regarding the examined parameters (k= 0.847, 0.937, 0.908, 0.953, 0.957), respectively. Fistula recurrence and minor FI were recorded in 4.2% and 14.7% of patients. MRI fistulography is an effective diagnostic modality for the preoperative assessment of FIA. MRI had excellent accuracy and sensitivity in detection of the internal opening, primary tract, and secondary extensions of anal fistula with very good concordance with the intraoperative findings.

Vesicouterine fistula: A case report of successful repair

The increasing rate of cesarean deliveries especially in previous scars is a major cause of vesicouterine fistula (VUF). The incidence of VUF is on the rise because of the increasing incidence of cesarean deliveries. VUF is a pathological communication between the uterus and the bladder. VUF presents in various ways, the main symptoms are urinary incontinence with or without hematuria. There could be depression or psychological distress, which may culminate in reduction in quality of life. The precise and early diagnosis of vesicouterine fistula may be difficult; thus necessitating myriad of investigations such as retrograde cystography, cystoscopy, contrast-enhanced CT scan, MR urogram, and transvaginal ultrasound with or without Doppler. Examination under anaesthesia (EUA) is crucial to the diagnosis of VUF and this includes methylene blue test. We report a case of VUF.

Management of pouch dysfunction in a tertiary centre.

Restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis is the operation of choice for ulcerative colitis (UC) and some cases of familial adenomatous polyposis (FAP). Although it offers improvement in quality of life and high patient satisfaction, pouch surgery is also associated with significant morbidity. The aim of this study was to describe the management of patients referred to a tertiary centre with pouch dysfunction. All patients referred with pouch dysfunction from other institutions between October 2006 and November 2014 were included in this retrospective study. Information regarding initial diagnosis before RPC, type of procedure, symptoms leading to referral, relation of the appearance of symptoms to the ileostomy closure, investigations, final diagnosis, treatment and follow-up was reviewed. One hundred and twenty-one patients were included, having had RPC mostly for UC (94%), and with diverting ileostomy (83%). The most frequent reasons for referral were high frequency of defaecation in 83 (69%) patients, abdominal pain and incontinence in 45 (37%) each and perianal pain in 44 (36%). The principal investigations performed were pouchoscopy in 97 (80%) patients, examination under anaesthesia (EUA) in 62 (51%), pelvic magnetic resonance imaging (MRI) in 56 (46%) and contrast radiology of the pouch (pouchogram) in 45 (35%). The commonest diagnoses were pouchitis (primary and secondary) in 24 (21%) patients and anastomotic leakage in 26 (22%). After full investigation a cause for the symptoms could not be found in 24 (20%) patients, resulting in the diagnosis of exclusion of 'irritable pouch syndrome' or functional disorder. The treatments given were long-term antibiotic therapy in 29 (25%) patients, ileostomy in 19 (16%), use of a Medena catheter to promote anal evacuation in 17 (15%) and dilatation of a stenosis under anaesthetic in 12 (10%). Six (5%) patients underwent major revision surgery of the pouch with a defunctioning ileostomy and the pouch was excised in another six (5%). Patients with ileoanal pouch dysfunction often have multiple symptoms. This study shows that a wide range of investigations and treatment modalities need to be available to manage such patients, with a specialized approach in a multidisciplinary setting.

Loco-regional staging of cervical carcinoma: Is there a place for Multidetector CT?

ObjectivesComputer tomography (CT) is the most widely used diagnostic modality in the routine evaluation of distant metastatic disease. We aimed to evaluate the role of Multidetector CT (MDCT) in local staging of cervical malignancies. Patients and methodsIn this prospective study 26 patients with pathologically proven cervical malignancies performed postcontrast MDCT of the abdomen and pelvis for local staging. Reconstruction of images was performed in the workstation. In a sample of 12 patients an extended study in which delayed images were obtained for more accurate ureteric evaluation. Data were analyzed using SPSS and McNemar test was used to calculate accuracy. ResultsThe overall accuracy of CT was 61.5% excluding the discrepancy in staging between CT and examination under anesthesia (EUA) due to distant metastases (three cases had distant metastases in CT which was not evaluated in EUA). This value was raised to 77% if vagina was assessed clinically rather than by CT. ConclusionIn cervical cancer; CT gave better results in staging of advanced cases than in early staged ones. Local staging was improved by acquisition of delayed scans.

A rare case of primary amenorrhea

Crytomenorrhea arises usually due to the imperforate hymen, sometimes due to vaginal septum, rarely due to cervical agenesis. Here, we present a case of primary amenorrhea resulting from cervical agenesis in a 38-year-old woman. She presented with primary amenorrhea and cyclic lower abdominal pain. She had undergone some surgery 5 years back, details of which were not available. On examination secondary sexual characters were normal, per abdomen there was an 18 weeks size firm abdominopelvic mass. Local vaginal examination showed a blind vaginal pouch. A clinical diagnosis of hematometra due to transverse vaginal septum was made. However, magnetic resonance imaging pelvis suggested hematometra with cervical stenosis. The patient was taken up for examination under anaesthesia (EUA) and exploratory laparotomy. On opening the abdomen uterus found to be enlarged with dense adhesions all around and signs of endometriosis. Extensive adhesiolysis revealed bilateral chocolate cysts of ovaries with hematosalpinges and peritubal adhesions. Hysterotomy and drainage of tarry contents were followed by an exploration of the uterine cavity. The lower pole ended blindly with no evidence of any cervix. Peroperative diagnosis of cervical agenesis leading to hematometra and endometriosis was made. A subtotal hysterectomy with bilateral salpingo-oophorectomy was done. Histopathological examination confirmed ovarian endometriosis and adenomyosis of uterus. Though reconstructive surgery for cervical dysgenesis has been successful in some cases, hysterectomy is generally recommended for cervical agenesis.

Impact of three-dimensional endoanal ultrasound on the outcome of anal fistula surgery: a prospective cohort study.

The aim of the study was to evaluate the impact of three-dimensional endoanal ultrasound (3D-EAUS) on postoperative outcome in patients with anal fistula. This prospective study compared clinical and functional outcomes of patients with and without preoperative 3D-EAUS examination 1 year after anal fistula surgery. Patients were prospectively followed and evaluated by a standardized protocol including physical examination, the Wexner Incontinence Score (WIS) and anorectal manometry, at baseline and 1 year after surgery. A total of 196 patients were enrolled. There were no significant differences in demographic and operative parameters, except for operation time, between the two groups. At 1 year follow-up, the overall recurrence rates were 8.8% (9/102) in the 3D-EAUS group and 13.8% (13/94) in the examination under anaesthesia (EUA) group. In the subgroup of patients with complex fistulae, the recurrence rate was numerically lower in the 3D-EAUS group (12.8% vs 22.5%; P = 0.26). The WIS in the EUA group significantly worsened (0.35 ± 0.94 vs 1.07 ± 1.59; P = 0.003) with a decreased the number of fully continent patients (82.5% vs 55%; P = 0.008) while neither the WIS nor the proportion of fully continent patients changed in the 3D-EAUS group. Fewer patients in the 3D-EAUS group developed incontinence postoperatively (6.7% vs 33.3%; P = 0.012) and they had better maximum resting pressure and maximum squeeze pressure than the EUA group. Preoperative use of 3D-EAUS had a favourable impact on the outcome of surgical treatment for anal fistulae, especially in those with complex anal fistula. It should be routinely used in the clinical setting.

Pregnancy Following Cervical Tuberculosis

Incidence of urogenital tuberculosis is a raising concern worldwide specially in developing countries, in most cases, primary foci may not be identified either due to ignorance of the individual or her family may remain unaware about the seriousness or consequences. In this case a multiparous reproductive aged woman presented with repeated episode of post coital bleeding. Most of the attending Physician confused with hormonal disturbance and treated with hormone and others for months in outreach area. Once upon a time however she was referred to Gynae OPD and after inspection of cervix she was advised for inpatient admission for Examination Under Anaesthesia (EUA) and biopsy. Histopathology report revealed chronic granulomatous lesion of the cervix and ultimately she was diagnosed as a case of tubercular ulcer of the cervix. After successful treatment by antitubercular medication as per schedule, she was conceived and gave birth to a healthy term baby. Pregnancy following cervical Tuberculosis (TB) is a rare incidence and probably not reported in literature. JCMCTA 2015 ; 26 (1) : 55-58

PWE-383 Defaecating proctography misses external rectal prolapse in 40% of cases

Introduction External rectal prolapse (ERP) is a debilitating condition for which the only cure is surgical. There are several ways to diagnose ERP including clinical examination, defaecating proctography (DP), and examination under anaesthesia (EUA). In many cases, a diagnosis of ERP is made clinically. In our unit DP is undertaken routinely in order to aid characterisation of ERP and aiding in planning operative strategy, even when clinically evident. This affords the opportunity to evaluate DP against the gold standard of clinical assessment/EUA. The purpose of this study is to investigate the accuracy of DP in the diagnosis of ERP compared to EUA or clinical examination. Factors that may influence failure of DP in the detection of ERP are also explored. Method Data were acquired from a prospectively collected database in a tertiary referral pelvic floor service. The search was limited to those patients referred with or having a final diagnosis of ERP. Patients were included in analysis if they underwent DP and clinical examination or EUA. The primary endpoint was accuracy of DP in the diagnosis of ERP compared to a definitive diagnosis reached either by clinical examination or ultimately at EUA. Factors explored to explain any discrepancy included age and anorectal physiological parameters including maximum resting pressure (MRP, mmH 2 O) (Mann-Whitney U test, α=0.05). Results 113 patients had a diagnosis of ERP between July 2007 and December 2013 (median age 64y, range 18–95y, 89% female). Of these patients, 67 underwent both DP and clinical examination/EUA. 27 (40%) had a diagnosis of ERP made only on clinical examination or EUA and not detected on DP. 2 (3%) had ERP detected on DP and not on EUA. In both of these cases, grade 4 prolapse was detected at EUA and ERP on DP. Median maximum resting pressure [range] was significantly higher in those in whom DP missed compared to showed ERP (43.5 [12–122] vs. 29.5 [6–122], p .05). There was no significant difference in other ARP parameters between the two groups. There was no difference in median age [range] between the two groups (62 [25–86] vs. 55 [22–80], p = 0 .29). Conclusion This study demonstrates the limitation of DP in the diagnosis of ERP. DP should be used with caution to diagnose the aetiology of a prolapsing lump described by a patient but not demonstrable clinically. In such patients, EUA should be considered. Patients in whom DP did not detect ERP had higher maximum resting pressure. The corollary of this may be patient difficulty reproducing ERP at DP because of better underlying sphincter function. Patients may also fail to produce their ERP at DP due to embarrassment associated with undergoing this invasive study. Disclosure of interest None Declared.

PTU-209 Intra-operative swab cultures do not predict the development of anal fistula in patients undergoing emergency incision and drainage of perianal abscess: Abstract PTU-209 Table 1

Introduction Routine swab cultures at the time of perianal abscess drainage remains common practice in modern day emergency colorectal surgery. We aimed to analyse the effectiveness of culture swabs to predict short term and long term outcomes of perianal abscess drainage. Method 350 consecutive patients from January 2008 to December 2010 undergoing incision and drainage (I&D) of perianal abscesses with packing of wound in community were analysed for readmission, follow up outpatient visit, repeat procedure for ongoing symptoms and presence of anal fistula at follow up examination under anaesthesia (EUA). Patients with inflammatory bowel disease and known anal fistula disease were excluded. Inter-group comparative analyses were made for patients with and without intra-operative culture swabs and for the microbial growth. Results Overall fistula formation rate after I and D was 12% at 36 month follow up. No statistical significant differences were found between the different groups for rate of readmission, presence of fistula and number of outpatient consultations (P > 0.05). There was no significant difference in fistula rates for patients with positive microbial growth and negative microbial growth (10% vs. 8%, p = 0.12). No significant variation was observed for different types of organisms and rate of fistula formation. (See Table 1). Conclusion Routine swab cultures do not influence short and long term outcome associated with I&D of perianal abscess. Disclosure of interest None Declared.

Cost-effectiveness analysis of clinic-based chloral hydrate sedation versus general anaesthesia for paediatric ophthalmological procedures

Background/aimsThe inability of some children to tolerate detailed eye examinations often necessitates general anaesthesia (GA). The objective was to assess the incremental cost effectiveness of paediatric eye examinations carried out...

A Novel Technique for Identification of Fractured Ceramic Acetabular Liner in Total Hip Arthroplasty: A Case Report

In total hip arthroplasty ceramic bearings are liable to fracture. We present the case of an 82-year-old male with groin pain and an audible squeak 6 months post ceramic on ceramic hip arthroplasty. Initial plain radiography and examination under anaesthetic (EUA) were normal. Fluoroscopy with normal image exposure was also unremarkable. Over penetration of the image intensifier film demonstrated a fracture of the ceramic acetabular liner. The patient subsequently underwent a revision of both acetabular and femoral bearing surfaces.Displaced ceramic liner fractures are easy to identify with plain radiographs. We recommend the use of over penetration using image intensification as a technique to help identify subtle ceramic liner fractures. To our knowledge this has not been previously reported in the literature.

Patterns of Treatment of Accidental Genital Trauma in Girls

Although pediatric genital injuries account for 0.2% to 0.8% of reported childhood trauma incidents, the number of pediatric genital injuries continues to rise despite public health measures aimed at decreasing childhood injury. While some authors advocate that all patients with accidental genital trauma (AGT) should undergo examination under anesthesia (EUA) in the operating room, other authors have reported that most children with AGT can be managed expectantly without surgical intervention. This study aims to delineate the characteristics of girls with AGT who can be managed in the Emergency Department (ED) as compared to those who require treatment in the Operating Suite (OS).

Role of tridimensional endoanal ultrasound (3D-EAUS) in the preoperative assessment of perianal sepsis.

The aim of this study was to evaluate the accuracy of tridimensional endoanal ultrasound (3D-EAUS) in the diagnosis of perianal sepsis comparing the results with the surgical findings, considered as reference standard. From January 2009 to January 2013, all the patients referred for the assessment and treatment of perianal sepsis with suspected anorectal origin were enrolled in the study. All patients gave informed written consent. Prior to surgery, all the patients underwent anamnestic evaluation, clinical examination, and unenhanced and H2O2-enhanced 3D-EAUS. Surgery was performed by a colorectal surgeon blinded to the 3D-EAUS results. A total of 212 patients with suspected perianal suppurations were assessed during the study period. In 12 patients, the H2O2-enhanced 3D-EAUS was not performed, and so, they were excluded from the study. Very good agreement between 3D-EAUS and examination under anesthesia (EUA) in the classification of primary fistula tracts (kappa = 0.93) and in the identification of fistula internal opening (kappa = 0.97) was found. There was a good concordance (kappa = 0.71) between 3D-EAUS and surgery in the detection of fistula secondary extensions. The overall sensitivity and specificity of 3D-EAUS in the diagnosis of perianal sepsis were 98.3 and 91.3% respectively. 3D-EAUS is a safe and reliable technique in the assessment of perianal sepsis. It may assist the surgeon in delineating the fistula tract anatomy and in determining the origin of sepsis, supporting the preoperative planning of definitive and appropriate surgical therapy.

Congenital pouch colon in girls: Genitourinary abnormalities and their management.

Aims:To discuss the assessment and management of genitourinary (GU) tract abnormalities in 21 girls with Types I-III congenital pouch colon (CPC), studied over a period of 10 years.Materials and Methods:Assessment included clinical and radiological assessment, examination under anesthesia (EUA), endoscopy of the lower GU tract, and evaluation of the surgical findings, operative procedures for the GU anomalies, and the results of management.Results:Initial examination of the external genitalia showed a “clover-leaf” appearance (n = 6) and a single perineal opening (n = 6). In 9 patients, the openings of the urethra and double vagina were seen, of which a vestibular fistula was seen in 5 and an anterior perineal fistula in 1. Seventeen patients (81%) had urinary incontinence (UI) - partial in 10, and complete in 7. Renal function tests, X-ray sacrum, and abdominal US were normal in all patients. Micturating cystourethrogram (n = 9) showed a wide, bladder neck incompetence (BNI) with reduced bladder capacity in seven patients. EUA and endoscopy revealed a septate vagina in all patients and the urethral opening at a “high” position (n = 14) or at a relatively normal or “low” position (n = 7). In 8 patients, the intervaginal septum was thick and fleshy. Endoscopy showed a short, wide urethra, an open incompetent bladder neck, poorly developed trigone, and reduced bladder capacity in the patients with UI. The fistula from the colonic pouch opened in the proximal urethra (n = 4), high in the vestibule (n = 3), low in the vestibule (n = 8), perineum just posterior to the vestibule (n = 1), and undetermined (n = 5). Vaginoscopy (n = 8) showed normal cervices in all and cervical mucus in 4 patients. The subtypes of CPC were Type I CPC (n = 4), Type II CPC (n = 16), and Type III CPC (n = 1). All 21 patients had uterus didelphys. In four patients with UI, during tubular colorraphy, a segment of the colonic pouch was preserved for later bladder augmentation if required. A Young-Dees bladder-neck repair (BNR) was performed in four older girls for treatment of UI, with marked improvement in urinary continence in two girls, some improvement in one girl with complete urinary incontinence, and minimal improvement in one child. Division of the intervaginal septum was performed in three girls.Conclusions:GU abnormalities in girls with CPC need to be assessed and managed by a tailored protocol. UI is frequent, and its correction may require BNR. A segment of the colonic pouch can be preserved for possible future bladder augmentation. All girls have a septate vagina, often widely separated, and uterus didelphys. Gynecologic assessment and monitoring is required throughout adult life. Considering the wide opening of the vestibule, surgical management of the urogenital component by division of the intervaginal septum and if required, the vagino-fistula septum on each side results in a normal or a hypospadiac urethral opening and an adequate vaginal inlet.

The effect of different methods of stability assessment on fixation rate and complications in supination external rotation (SER) 2/4 ankle fractures.

Distinguishing stable supination-external rotation (SER) 2 from unstable SER 4 ankle fractures, using standard radiographs, is controversial. Examination under anaesthesia (EUA), gravity-stress (GS) and weight-bearing (WB) radiographs can aid surgical decision-making. We evaluated the effect of three methods of fracture stability assessment. Radiographs and case-notes of 312 consecutive patients with SER 2/4 fractures were reviewed. We recorded ankle stability assessment (plain film (PF) and EUA vs. GS vs. WB radiographs), management (conservative vs. operative), unplanned surgery and complications. Forty five percent assessed with GS underwent surgery (6% for PF/EUA, 4% for WB; P=0.0001). Amongst GS patients, 11% underwent additional surgery (0.1% PF/EUA, 0% WB; P=0.0001). Complications occurred in 2% of the WB group (8% for PF/EUA, 22% for GS; P=0.007). This study associates GS assessment with higher rates of surgery and complications. Subsequent studies may determine the longer term effect stability assessments have on post-traumatic arthritis.

Associations between isolated bundle tear of anterior cruciate ligament, time from injury to surgery, and clinical tests.

To evaluate the associations between isolated anteromedial (AM) or posterolateral (PL) bundle tear of the anterior cruciate ligament (ACL), the time from injury to surgery, and various clinical tests. 36 women and 189 men aged 16 to 52 (mean, 26.4) years underwent ACL reconstruction of the right (n=107) and left (n=118) knees. Patients were evaluated for the International Knee Documentation Committee Subjective Knee Score, Cincinnati Knee Rating System Score, anterior drawer test, Lachman test, pivot shift test, KT1000 arthrometer measurement, isokinetic muscle tests of the extensors, and functional tests (single leg hop and timed hop test). Examination under anaesthesia (EUA) was also performed, followed by diagnostic arthroscopy. The integrity of the ACL bundles was tested using a probe. The AM and PL bundles were morphologically intact if structurally present, and functionally intact if not lax on probing. Of the 225 patients, 8 had isolated AM bundle tears, 2 had isolated PL bundle tears, and 215 had complete ACL tears in terms of function. The corresponding numbers were 30, 13, and 182 in terms of morphology. Compared with patients with complete ACL tear, the mean time from injury to surgery was significantly shorter in patients with isolated AM or PL bundle tear in terms of function (17.5 vs. 5.6 months, p<0.001) and morphology (17.5 vs. 8.8 months, p<0.001). Compared with patients with complete ACL tear, those with a functionally intact PL bundle had a higher rate of negative pivot shift test in preoperative evaluation (1% vs. 17%, p=0.002) and EUA (1% vs. 63%, p<0.001), and had a higher rate of negative Lachman test in EUA (1% vs. 25%, p=0.02). The time from injury to surgery was shorter in patients with isolated bundle ACL tear. In patients with ACL deficiency, the pivot shift test was useful in detecting an intact PL bundle.

Examination under Anesthesia: An Invaluable Tool for Localizing Retroperitoneal Tumors

Examination under Anesthesia: An Invaluable Tool for Localizing Retroperitoneal Tumors Pelvic examination under anesthesia (EUA) is an outmoded diagnostic method that helps localize and evaluate deep pelvic organs and structures. We report a rare case that confirms the eternal value of this investigative tool.

Anorectal fistula is an early manifestation of Crohn's disease that occurs before bowel lesions advance: a study of 11 cases.

The diagnostic significance of single-balloon enteroscopy (SBE) in patients presenting with Crohn's disease (CD)-like anorectal fistula is unknown. We experienced 11 cases undergoing SBE due to CD-like fistulas between December 2007 and April 2013. The mean interval from fistula onset to SBE was 19.2months with a range of 1.3-44.7. Prior to SBE, all patients underwent anorectal examination under anesthesia (EUA), and 9 patients underwent total colonoscopy with terminal ileal cannulation (TCS-I). One of 7 patients undergoing upper gastrointestinal endoscopy had CD-like gastritis. EUA revealed CD fissures in 7 patients, 1 of whom had no intestinal lesion. Primary TCS-I identified early lesions, such as aphthes and small ulcers, in 4 patients. Among the other 5 patients without any intestinal lesions with TCS-I, SBE indicated early lesions in 3 patients. One of 2 patients who initially underwent SBE without TCS-I showed multiple aphthes. Of the 11 patients, only 4 patients fulfilled the definitive Japanese diagnostic criteria for CD and 7 remained 'suspected CD' cases. Intrinsic anorectal fistulas as a presenting symptom of CD may be an early predictor of bowel lesions. SBE has the potential to reveal incipient disease because an early ileal lesion is not rare for patients with anorectal fistulas.

Clinical Application of the "Glenoid Track" Concept for Defining Humeral Head Engagement in Anterior Shoulder Instability: A Preliminary Report.

Background:The optimal treatment of Hill-Sachs injuries is difficult to determine and is potentiated by the finding that a Hill-Sachs injury becomes more important in the setting of glenoid bone loss, making engagement of the humeral head on the glenoid inherently easier. The “glenoid track” concept was developed to biomechanically quantify the effects of a combined glenoid and humeral head bony defects on instability.Purpose:To clinically evaluate humeral head engagement on the glenoid by utilizing glenoid track measurements of both humeral head and glenoid bone loss.Study Design:Retrospective cohort.Methods:A total of 205 patients with recurrent anterior shoulder instability were evaluated, and of these, 140 patients (68%; 9 females [6%] and 131 males [94%]) with a Hill-Sachs lesion and a mean age of 27.6 years (range, 15-47 years; standard error of mean [SEM], 0.59) were included in the final magnetic resonance angiogram [MRA]) analysis. Bipolar bone loss measures of glenoid bone loss (sagittal oblique MRA) and multiple size measures of the Hill-Sachs injury (coronal, axial, and sagittal MRA) were recorded. Based on the extent of the bipolar lesion, patients were classified with glenoid track as either outside and engaging of the glenoid on the humeral head (OUT-E) or inside and nonengaging (IN-NE). The 2 groups were then compared with clinical evidence of engagement on examination under anesthesia (EUA) using video arthroscopy, number of dislocations, length of instability, and patient age.Results:The mean glenoid bone loss was 7.6% (range, 0%-29%; SEM, 1.20%), and 31 of 140 (22%) patients demonstrated clinical engagement on EUA. Radiographically, 19 (13.4%) patients were determined to be OUT-E, while 121 (86.6%) were IN-NE and not expected to engage. Of those 19 patients with suggested radiographic engagement (OUT-E), 16 (84.5%) had clinical evidence of engagement versus only 12.4% that clinically engaged (15/121) without radiographic evidence of engagement (IN-NE) (P < .001). Younger age and a greater number of recurrence events were jointly predictive of a patient being classified as OUT-E (11.8 vs 6.4 dislocations; P = .015).Conclusion:This study demonstrates that glenohumeral engagement was well predicted based on preoperative glenoid and humeral head bone loss measurements using the glenoid track method. In addition, younger age and a greater number of recurrences were predictive of engagement. The glenoid track concept may be important to fully assess the overall risk for engagement prior to surgery and may help guide surgical decision making such as bony augmentation procedures.